Fraud Prevention

The United Nations Mutual Insurance Society Against Sickness and Accident (UNSMIS) takes a zero tolerance approach to any form of fraud. Fraud jeopardizes the long term financial viability of the insurance plan and escalates costs for insured Staff, Retirees and respective dependents as well as for the participating Organisations, Funds, Offices and Programs. In short it threatens the existence of your medical insurance plan.

In accordance with the comprehensive Anti Fraud and Anti-Corruption Framework (ST/IC/2016/25), , UNSMIS , as an integral part of UNOG , is duty bound to ensure that the “The promotion and maintenance of a culture of integrity and honesty is a basic requirement for combating fraud and corruption, and a primary responsibility of management and staff at all levels” This applies to all insured members of UNSMIS.

False claims, falsifying documentation, the provision of misleading information, the withholding of information related to this claims, seeking double reimbursement from different insurance providers and using the funds received from UNSMIS for the settlement of claims submitted for anything other than settling of said medical expenses reimbursed is considered fraudulent behaviour and can incur administrative sanctions and result in the suspension of entitlement to UNSMIS.

The insured Member is responsible for the submission of medical insurance expenses for reimbursements for themselves and their insured family members. It is the duty of Members to ensure that all requests for reimbursements include veritable and correct information, submitted in utmost good faith and that any material facts be proactively disclosed. A material fact is a fact that may change the profile of the claim.

Examples of Fraud:

  • Seeking reimbursement for expenses already reimbursed by another private insurance or a social security system. The failure to disclose the material fact that reimbursement has already been effected by another source can be deemed a fraudulent. The correct approach would be to specify what portion of the expenses submitted have already been reimbursed so that UNSMIS may act as a complementary insurer and reimburse any out of pocket expenses, if reimbursable in accordance with the Internal Rules.
  • Receiving the reimbursement for medical expenses presented to UNSMIS and using the money for any other purpose other than settling the medical bills. By doing so insured members jeopardise the image of UNSMIS and that of the United Nations. It is the Member’s responsibility to ensure that all medical expenses for themselves and their family members, irrespective if submitted to UNSMIS or not, be duly settled.
  • Receiving the reimbursement for medical expenses presented to UNSMIS and then agreeing, after the reimbursement, with the provider a further discount or settlement of the invoice(s) in instalments.
  • Manually altering and/or forging medical invoices, prescriptions, sick leave certificates, medical reports and bills as well as any other form of documentation requested, necessary or presented to UNSMIS for settlement of medical expenses.
  • Colluding with a medical provider to provide fake, altered or incorrect prescriptions, reports, invoices and certificates. This also includes cases where the insured member and the medical provider seek to alter invoices and actual amounts paid so as to avoid paying any out of pocket amounts.

The above are only some of the examples and is to be considered in no way an exhaustive list.

In addition to the Anti-Fraud and Anti-Corruption Framework the UNSMIS Internal Rules , Rule VIII, paragraph 8, also specify that the Executive Committee “…-may decide that a member or an insured person has forfeited all or part of his entitlement to  benefits  from  the  Society,  or  that  such  entitlement  shall  be wholly or partially suspended;

  • If  an  insured  person  fails  to  comply  with  the  provisions of these Statutes and Internal Rules;
  • If  it  is  established  that  the  person  concerned  has  attempted  fraudulently  to  obtain  benefits  to  which  he  or  she was not entitled;
  • If  a  member  or  one  of  the  persons  protected  by  the  Society   refuses   to   undergo   a   medical   examination prescribed by the Committee or by the Medical Adviser;
  • If the member is late in paying the premiums due after separation from service.

Suspected cases of fraud or abuse must be reported. Staff Rule 1.2 (c) states that “Staff  members  have  the  duty  to  report  any  breach  of  the  Organization’s regulations  and  rules  to  the  officials  whose  responsibility  it  is  to  take appropriate action...” Once again please refer to the Anti-Fraud and Anti-Corruption Framework on how to report Fraudulent Acts and to ensure protection against retaliation. 

UNSMIS would also like to inform Members that we may occasionally carry out spot checks and request additional information that we normally would not. This is part of our fraud prevention/ detection efforts and should in no way be viewed as an accusation or an insinuation. We kindly request your full collaboration. Failure to provide the requested documentation will slow down the processing of your claim.